Provider Demographics
NPI:1396981312
Name:HICKS, DESAK G (RPH)
Entity type:Individual
Prefix:
First Name:DESAK
Middle Name:G
Last Name:HICKS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:COFFEEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36524-5012
Mailing Address - Country:US
Mailing Address - Phone:251-276-3400
Mailing Address - Fax:251-276-3562
Practice Address - Street 1:873 HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:COFFEEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36524-5012
Practice Address - Country:US
Practice Address - Phone:251-276-3400
Practice Address - Fax:251-276-3562
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL11671183500000X
AL1133453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009501290Medicaid
AL009501290Medicaid